Module 1

Introduction to Health Link

& How to Identify and Engage a Client for a

Coordinated Care Plan

Mid East Toronto Health Link

Let’s Make Healthy Change Happen

Health Link Approach

Health Link brings together health and community support service

providers to better integrate care and facilitate transitions

between providers across the health care continuum for clients with

the most complex needs.

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Primary Care

Community Support

Services & Community

Care

Supportive Housing

Community Mental Health

Hospital

Integrate Care Facilitate

Transitions

Client with

complex

conditions

Health Link Background

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Top 1% of users = 35% of cost

Top 5 % of users = 65% of cost

Top 10% of users = 77% of cost

• Top 5% of residents account for 2/3 healthcare

spending

• These individuals tend to have multiple chronic

conditions, poorly integrated care, high hospital

utilization

• Therefore, engaging primary care is key

• The goal is to improve health outcomes and client

experience

Health Link Approach

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• Focus is on breaking down silos. Leverage the skills, experience,

knowledge and relationships of frontline providers

• Better outcomes when their care is coordinated between hospital, with

primary care, community care, community services and/or the other sectors

• It is effective when frontline providers have lead roles in this work.

• Coordinated Care Plans (CCPs) document this integrated approach to

care

• Community agencies in Toronto Central LHIN are developing over 3,000

CCPs annually. There are presently an estimated 60,000 patients with

complex conditions in TCLHIN.

• In Ontario, 84 707 people have CCPs. Approximately 5000 are developed

every quarter.

Outcome 1: Coordinated Care Plans (CCPs)

• The Health Link approach to care has typically resulted in a

significant reduction of both Hospital Emergency

Department visits and In-patient stays, as evidenced in the

North Simcoe Health Link data.

• At 12 months of involvement in Health Link coordinated care

planning and management, there was a reduction of nearly

40% in ED visits and over 60% in IP stays. These

improvements were consolidated over time; at 19 months,

there was a nearly a 50% decrease in ED visits and a 70%

decrease in IP stays.

• ED acuity scores for non-urgent issues (CTAS 3, 4 and 5)

also significantly decreased.

Source: North Simcoe Health Link

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In Mid-East Toronto, client level impacts of our Coordinated Care Plans have

typically included:

• Improved access to much needed housing, primary care, home and

community care services, interdisciplinary care teams, community

support services and social supports

• Improved adherence to treatment protocols, including mental health

and/or addictions treatments and services

• Improved access to and benefit from capacity assessments, crisis plans,

infirmary level care and Long Term Care

• Improved access to appropriate longer term case management support

• Improved family/partner relationships and client and self-esteem and

coping skills

• Ongoing health care system navigation and advocacy where none had

otherwise been available

Source: HQO Health Link Report Q1 2019-20

Outcome 1: Coordinated Care Plans (CCPs)

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Pre-CCP: Sue is a 56 year old with bipolar and

ABI (resulting in epilepsy and mobility issues).

Sue was a frequent ED user due to constant

seizures, alcohol misuse, hyponatremia,

medication non-compliance, broken collarbone

and general failure to thrive. She had serious

financial difficulties, had a market rent

apartment and was in rent arrears. Sue was

referred to Health Link by the hospital.

A CCP was developed involving TCLHIN

Home and Community Care, Outpatient

Psychiatrist, Cota Case Management,

Neurology and Sue’s family doctor.

The CCP was updated to focus on finding a

solution for Sue’s inadequate housing and

financial challenges. New partners were invited

to this meeting- WoodGreen, Neighbourhood

Link and LOFT to brainstorm on housing

options.

Through the CCP process: Neighbourhood Link offered Sue an

apartment in a transitional supportive housing building where other

supports were available and rent was much more affordable. Sue

was placed on a seniors housing waitlist for longer term housing.

Over time, she became financially stable, and self-sufficient. Sue

purchased her own dentures and opened a savings account. Sue

became diligent with her medications and is completely medication

compliant.

Sue was referred to Neuropsych at TWH and now receives ongoing

support for mental health symptom management. Sue participates

in social activities in her building and is feeling less depressed. She

attends her own appointments and books her own Wheel Trans,

rarely missing appointments. She has stopped using problematic

drugs now for 2 years and has managed to moderate her alcohol

use significantly. She has now been out of hospital for alcohol use

for 3 years. Sue is more confident and has more self-esteem, and

is able to advocate for herself.

Sue is being transferred to less intensive long term case

management in the building where she is living from the same

organization currently providing case management so the transition

should be smooth.

Outcome 1: Coordinated Care Plans (Virtual Hub Client Story)

Health Link Core Mandate

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Identify and Engage Patients/Clients with Complex Health Needs

Develop Coordinated Care Plans (CCPs)

Offer/Strengthen Attachment to Primary Care

What results from Coordinated Care Planning

and Management?

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What are the Guiding Principles for

Coordinated Care Planning?

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Health Quality Ontario Coordinated Care Management Process

This module covers Steps 1 & 2 in the process

Target Population for Health Links

Target

Population

Patients or clients with 4 or more chronic and/or high cost

conditions

Considerations

Consider patients or clients with:

• Economic characteristics (low income, low median

household income, government transfers as a proportion of

income, unemployment)

• Social determinants (housing and homelessness,

transportation challenges, living alone, language barriers,

immigration, community and social services etc.)

• Hospital Utilization: Frequent ED visits, multiple In-Patient

stays, multiple medications

Identified

Sub-Groups

Mental Health &

Addiction

Palliative Frail Elderly

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Chronic and/or High Cost Conditions Checklist (client to have 4 or

more chronic or high cost

Chronic and/or High Cost Conditions – 4 or More

ALS (Lou Gehrig’s Disease) Amputation Anxiety Disorders

Arthritis and Related Disorders Asthma Bipolar

Blood Disorders (anemia, coagulation defects)

Brain Injury Cardiac Arrhythmia

Cerebral Palsy Chronic Obstructive Pulmonary Disease Coma

Congenital Malformations (Congestive) Heart Failure Crohn's Disease/Colitis

Cystic Fibrosis Dementia Depression

Developmental Disorders Diabetes Eating Disorders

Epilepsy & Seizure Disorders Fracture Hernia

Hip Replacement HIV/ AIDS Huntington's Disease

Hypertension Influenza Ischaemic Heart Disease

Knee Replacement Liver disease (cirrhosis, hepatitis etc.) Low Birth Weight

Malignant Neoplasms (cancer)

Mental Health Conditions (unspecified/unknown)

Multiple Sclerosis

Muscular Dystrophy Osteoporosis Including Pathological Bone Fracture

Other Perinatal Conditions

Pain Management Palliative Care Paralysis And Spinal Cord Injury

Parkinson's Disease

Peripheral Vascular Disease and Atherosclerosis

Personality Disorders

Pneumonia Renal Failure Schizophrenia & Delusional Disorders

Sepsis Stroke Substance Related Disorders

Transplant Ulcer

Identify Clients for Health Links

Identify appropriate clients based on the Health Link target

population criteria and your own clinical judgement.

To help identify a client for Health Link approach, consider:

• Would this individual benefit from greater coordination of

care?

• Does this individual experience gaps in their care or struggle

to access the services they need?

• Do they have multiple Emergency Department visits or In-patient

stays? Are they at risk for ongoing ED visits?

• Do they have, or would they benefit from, multiple providers

being engaged more closely in their care?

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Invite and Engage Clients

• It is important to explain the purpose of the coordinated

care planning and management process to the client.

• You will need to obtain their agreement to participate in

the process.

• The next slide shows some examples of what you can say

to engage a client and obtain their consent to participate.

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Invite and Engage the Patient or Client

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I know a program that can help you. It’s called Health Links. It can be hard to keep track of what the different people involved in your health care may tell you – your doctor, the hospital, case worker etc. And these different providers are not necessarily talking to each other.

Health care providers can often come up with a better plan if they all work together as a team with you. Sometimes, separate medical advice given to you, the patient, isn’t the easiest approach.

It’s important for all of your providers to understand your situation and what is most important to you, so the work they do for you meets your needs and is more coordinated.

If a client declines, try re-engaging them over time. It may take multiple attempts before you get a “yes”.

I am suggesting we develop a coordinated care plan. We would start off talking about your goals, or what you feel is most important. Then we can decide who else we wanted to bring into the conversation. You are the driver and make these decisions. I think this approach could really work. How does it sound to you?

Module 1: Review Questions

• How do you know if a given client is appropriate for a coordinated care

plan (CCP)?

• How can the Health Link approach to care positively benefit your clients?

• What are several of the guiding principles for coordinated care planning

and management?

• How do you know who should lead a CCP for a client?

• How would you present the opportunity for a CCP to a client?

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Module 2

How to Gather Information from the Client,

Initiate the Care Plan & Share Information

Mid East Toronto Health Link

Let’s Make Healthy Change Happen

Health Quality Ontario Coordinated Care Management Process

This module covers Step 3 & the first part of Step 4

Gather Information / Build Rapport

• Once you have engaged the client on Health Link, you may still want to

continue spending time building rapport and trust with them.

• When trust is established, you can start or continue to gather

information.

• Tailor the questions you ask in ways that respond to the unique

individual, relationship and situation.

• Always use client focused language. For example:

What are struggling with most?

What would you most like to change?

Who might you like to have included in a discussion on how to

help?

Do you have a family doctor who we should involve?

Note: You may begin gathering information and initiating the CCP with your client on your own,

or you may do this at the Care Conference with the other providers present. That said, completing

the CCP should always take place at the care conference - but more on this later.

Gather Information

• When you are gathering information from the client, you may find that

the client is struggling with a variety of issues, so listen for what the

priority issues are.

• Issues may not seem to be “health-related” at first, but it is important

to think about the health component to them.

• A given issue may touch on multiple areas. Start to think about how

any given issue affects the areas below:

Physical Health

Mental Health

Life Plans

Self-Care

Relationships

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Initiate Care Plan

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Depending on your conversations with the client so far, you may already have

some of the information needed for the CCP. Below are the first three topics

covered in the CCP with corresponding client-centered questions.

Care Team members may include: Patient, Caregiver, Friend/Family, Primary Care Provider, Allied Health Provider, Hospital Staff, Care Coordinator, Volunteers (i.e. Friendly Visitor), Community Support Service Worker, Case Manager, Mental Health Worker, Psychotherapist/ Counselors, Sponsors, Church/Community Leaders etc.

What name would you like us to use?

What pronoun should we use to address you?

Is there anything we can do to help you share about your health?

Do you require any accommodations?

What is most important to you right now?

What parts of your day do you look forward to the most?

What most concerns you about the state of your health?

Are there ways that you think your health care could be improved?

Who can help you achieve your goals?

Which of these individuals do you want to involve in your care plan

meeting/care conference?

Who do you feel comfortable sharing the completed Care Plan with?

…use this to

determine who

to invite to the

care conference

and possibly who

might be best

position to lead

the CCP, if not

yourself

Initiate Care Plan: Health Care Consent and

Advance Care Planning Section on CCP

• There is section on the bottom of the first page of the CCP on

identifying Substitute Decision Makers (SDM)

• Under the Health Care Consent Act, 1996, an SDM must be the

highest in the ranking and must meet all the statutory requirements in

order to consent or refuse to consent to treatment on an incapable

person’s behalf.

• If the patient answers “No” to the question on the CCP “I have shared

my wishes, values and beliefs with my future SDM as they relate to my

future health care?”, consult the advanced care planning (ACP)

approved resource (e.g. “Speak-Up Ontario ACP Workbook” or

website information www.speakupontario.ca)

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Share Information/Engage Care Team

• Once you have a general understanding of the individual’s

situation and priorities, obtain the client’s consent to invite care

team members to participate in the Care Planning process.

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Remember: Always follow your organization’s policies and protocols to obtain client consent to reach out to others in their

circle of care and share information with them.

Topics to Cover when Engaging Care Team Members When you call the Care Team members, introduce yourself and explain:

• What: You are leading the Coordinated Care Planning and Management

Process for the Patient/Client and that they have been identified as part of the

client’s Care Team.

• Why: Describe what the process aims to do, i.e. help to integrate care for the

patient, create a more seamless experience, bring everyone together around

the client’s goals, and enable smooth transitions.

• How: Explain that you are organizing a Care Conference to discuss the

client/patient’s goals in more depth and how the patient and care team can work

together collaboratively.

• Explain what will be expected of the provider, i.e. to share information,

participate in care conference(s), provide updates, and work collaboratively on

patient goal(s) with others in the care team. The provider may need to obtain

their own consents from the client to be able to share information with you.

• When & Where: Determine and share info on when and where the care

conference take place.

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Brief Sample Script for Engaging Care Team

Members

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Hello, I am X and I am leading a coordinated care planning process for Client A. This is essentially a shared approach to managing care and tracking progress towards a client’s goals. It is focused

on facilitating smooth transition and integrated care.

You have been identified as part of Client A’s Care Team, and as you may know, Client A has the following conditions and challenges...

As such, I think there will be real benefit to bringing the Care Team together in a Care Conference to discuss how we can support Client A in meeting their goals, both as individuals and as a team. This should create a more seamless experience for A and make it easier for you to care for them.

Do you have any questions about this?

Are you available to participate in a meeting at X date, location & time? It should take about 60 minutes of your time, but could be less or more depending.

Tips for Engaging Physicians

Mention that:

• Physicians can bill for participation in Care Conferences.

Forward them the Physician Billing Code sheet. (Note: this does

not apply to CHC physicians as they are salaried)

• The physician can call in for the whole call, or just at the

beginning or the end of the call if that is what their schedule

permits

• You may ask the physician if the care conference can take

place at their offices if the client feels comfortable going there

and if it will increase the likelihood of the physician participating.

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Module 2 Review Questions

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1. What are some ways to build trust and rapport with your client in

order to facilitate an effective CCP?

2. At what point can you start to gather information from your client

for the CCP?

3. Why is it important to ask a client “what is most important” to

them as the starting point for a CCP?

4. Which policy should you follow in terms of obtaining client

consent to reach out to others in their Care Team?

5. What are three important ways you can encourage physician

engagement in a CCP?

Module 3

How to Conduct a Care Conference,

Complete the CCP and

Re-assess and Transition Client

Mid East Toronto Health Link

Let’s Make Healthy Change Happen

CCP Care Conference – Prepping for your first Care

Conference 1. Participants: The care conference should include at least 1 other person, plus

yourself and the client. Invite only the individuals the client has identified as

important to involve in a conversation about how to help with what is most important

to them, i.e. care team page 1 CCP.

2. Consider starting small: It can be a good idea to start this group small and grow

in accordance with the client’s comfort level. Ask the client who they would like

to invite to the first care conference.

3. Set expectations: Provide copies of the CCP template to everyone participating in

advance of the meeting and explain the purpose. Review the template and goal of

the CCP with both the client and the participants independently prior to the care

conference.

4. Organizing: If you cannot get everyone together at one time, you may need to hold

multiple care conferences, or use teleconference for some participants. It is

key that the client participates but if the client chooses not to be present for the

care conference and provides consent for you to go ahead without them, you may.

Take notes during the care conference and later fill out the CCP document. It can

be very helpful to have a colleague support you with note-taking while you facilitate

the discussion.

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Conduct Care Conference – Getting the Care

Conference Started

1. Start the care conference with welcome and introductions. Frame the

discussion as focused on better understanding the client’s situation and

goals and as an opportunity to discuss everyone’s roles and

responsibilities in helping the client achieve their goal(s).

2. Listen to what is most important to your client. Always keep the

discussion focused on this. If you completed page 1 of the CCP on your

own with the client (initiate CCP), review this with the care team. Ask the

client if anything from Page 1 of the CCP has changed or needs

updating.

3. Complete the rest of the client’s CCP at the Care Conference. This

should be done as a conversation, and not as simply filling out a form.

Here are some examples of how to do this as a conversation…

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Conduct Care Conference – Client Perspective on their

Health

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This section looks at the client’s health issues and the challenges these have

created in their lives, from the client’s perspective.

Below are some client-centered questions to help bring this information to the

surface. Ask Care Team members to augment/complement the information if

this is needed and appropriate.

Conduct Care Conference – Client Perspective on their

SdH

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Examples of questions you can ask in the “More About Me” section on the CCP (more

included in “Client-centered Question Guide Document or CCP User Guide”):

Income

• Do you have difficulty making ends meet at the end of the month?

• Have you recently been unable to fill your prescriptions, been unable to get to your

doctor’s appointment, or purchase the food you need?

• If the client if having difficulty making ends meet, you can ask about their sources of

income. Perhaps say: “I don’t need to know how much your income is, just the

sources of income to see if other resources are available to help you.”

Social Network

• How do you spend your day?

• Do you have people you can talk to?

• Do you have any big events taking place this year?

• Do you feel you have someone to talk to if you have a problem?

Conduct Care Conference - Identify Goal(s)

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• Summarize what has been discussed in the “My Health” discussion and the

“More About Me”. Describe where you see connections. Invite others’ thoughts.

• I’ve heard you mention that you’re experiencing X (health) symptoms and are

also struggling with Y and Z (economic) issues right now. Do you think these

are interacting with each other? Examples may be: Diabetes impacted by lack

of food security, Depression impacted by poor social network, Substance

challenges impacted by lack of stable housing, etc.

• Ask the client to suggest goals based on these inter-relationships. In the above

examples, what might some goals be? If the client is not able to create goals, suggest

some examples of actionable goals and invite feedback on these goals from the

client.

My Goals

and Action

Plan

This section is extremely important as it focuses on the patients’ goals and defining who

will do what to support them with achieving these goals.

What are the top 3 things you want to focus on improving or changing?

What are some steps we can take as a team to work toward this goal?

Are there people or services missing from your care team for this goal to be possible?

Who do you want to help you with X?

Action Plan with Care Team

• With each goal, invite care team members to share their perspectives on

how, given their individual expertise, they will support the client to

reach the given goal(s).

• Ask the care team members to discuss the support they will provide

and suggest any other individuals or resources that could assist.

• Strive to develop collaborative approaches where care team members

are working with a team approach. These are approaches where care

team members will be required to connect and communicate regularly

with one another.

• What might some examples be of a collaborative approach?

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Finish Completing the CCP

In addition to My Medication Coordination, there are several appendices to the

CCP which are optional as they may or may not apply to the individual case.

These include:

1. Medication List

2. Record of other Health Assessments

3. Most Recent Hospital Visit

4. Palliative Approach to Care

Discuss with the Care team which ones which relate to your client’s needs and

goals and complete only these. You may not have time to complete these at

your first care conference and may need to return to them at a subsequent

care conference.

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Wrapping up the Care Conference

1. Review roles and responsibilities of the care team members. You may

want to say:

“Let’s spend the last few minutes summarizing the meeting, what our

next steps are, and any timelines relating what we’ve discussed. This

is so that we’re all clear around what each of us need to do after we

leave the care conference”.

2. Request care team members provide you with updates

3. Develop/agree on a communication plan highlighting when and how the

care team will communicate

4. Summarize and close the meeting with a check-in.

“How are you feeling about what we discussed and achieved today?

What did you find most valuable about this meeting?”

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Directly After the Care Conference

1. Send a completed copy of the CCP to each conference participant via email

if they have secure email or otherwise via fax or hardcopy.

2. Ensure that the date the CCP was completed is indicated clearly on the

CCP. This will help with clarifying which version of the CCP is the most

recent.

3. Meet with the client separately to review the CCP. Ask them how they

feel about the plan and if they have concerns.

4. Document your work in the CCP monitoring and tracking materials.

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Reassess the Client – Reconvene Care Team

• Reconvene the Care Team and/or update the plan when:

a) a client’s health status changes or other changes to medication,

lifestyle, address or social determinants of health occur

b) you have agreed to reconvene (i.e. monthly, quarterly etc.)

• When you reconvene, assess the client’s progress towards their goals.

How is the client doing?

Are there any successes or challenges to report? Adjust the plan

based on what you hear

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When to Update the Care Plan

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Updating the Care Plan:

• It is the responsibility of care team members to update you if there are significant

changes that they become aware of regarding the client’s situation or health

status. Be sure to explain this to participants at the care conference.

• As the Lead, you should make updates to the first version of the client’s

Coordinated Care Plan as you learn about changes from the client, or from others

in the care team. If the changes are relevant/significant, you may be important

to reconvene the care team. You may also make changes to the CCP in the

interim and send care team members the new copy.

• The Care Team should have ongoing communication with each other.

• The Care Plan should be considered “evolving”, not stagnant. Save each version

of the Care Plan with the date it was updated on. Be sure to distribute each new

version (applicable to those not on eCCT)

Action Plan Follow-up:

• It is a good idea to follow-up with individuals who have responsibilities as outlined

in “My Goals and Action Plan” section. You should check-in between Care

Conferences regarding how the work is coming along.

Transitioning Clients

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As the client’s needs change over time the care plan should change with

them. A client’s ultimate goal may simply be to remain healthy with support of

team - the team would continue to evolve and work together.

A client is “discharged” from Health Link/CCP and no further Care

Conferences take place when:

• All of the client’s/SDM’s goals are met

• The client/SDM withdraws consent to continue the coordinated care

planning and management process.

• The client passes away

Interim Lead: In some cases, you may be providing interim leadership for the

CCP while an appropriate long-term lead is being sought. Sometimes, a

client’s situation changes in ways that make another lead more appropriate.

• In these cases, ensure full support for the transition to the longer-

term lead. Share all related documentation and be available for

questions related to the Care Plan or the coordinated care planning and

management process.

Module 3: Review Questions

1. Who should be involved in a Care Conference?

2. What should the conversation at a Care Conference focus on?

3. How can you facilitate collaboration in the Care Conference? What are

some examples of collaboration benefitting client care?

4. When should the Coordinated Care Plan be updated and who has the

responsibility for sharing updates?

5. When should you reconvene the Care Team?

6. In which instances should a client be “discharged” or transitioned from

Health Link/CCP?

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